1. Field of the Invention
The present invention relates to insurance claim processing systems in general, and more particularly to administering, tracking and managing insurance claim processing systems.
2. Description of the Background Art
Processing, tracking and releasing funds for claims made upon insurance policies and similar risk shifting mechanisms has traditionally been a time intensive and resource intensive process. Traditionally, there are six major steps involved in the processing of claims: initial claims processing, loss appraisal, claims adjusting, satisfying the claim, settlement and payment, and management and analysis.
Initial claims processing includes receiving initial claim data associated with a newly asserted claim, initial assessment of damages and tasks required to fulfill the claim, and assignment of those tasks to appropriate service providers.
The claims process starts with the notification by the insured or claimant that an accident has occurred. Currently, this notification is typically completed by phone to the carrier's first report unit or to an agent. The carrier then verifies policy coverage, creates a claim file and assigns the claim to an adjuster and an appraisal resource or directly to a service provider. Generally, the client must exchange several phone calls with the various commercial participants to schedule a damage estimate, select a repair facility and make car rental arrangements, if applicable. In addition, these processes are paper intensive because legacy claims systems do not support imaging and relevant documents such as estimates, photos, police reports and tow bills that arrive regularly by fax and mail throughout the life of the claim file.
Automated initial claim capture systems are known. However, while relieving some of the burden on an insurance carrier's resources, traditional automated initial claim capture systems are not flexible. Claimants are forced through standardized questions in standardized formats that often do not fit well with their needs. Also, these systems are not configurable to use by a commercial participant or a claimant, nor do they are unable to fully facilitate the capture of supplemental information in addition to initial claim data and can thus be inaccurate. Moreover, initial claim capture systems usually connect directly to an insurance company's proprietary software or interface. An agent who deals with multiple insurance companies may need multiple systems or pieces of software.
Initial claim processing also involves determining the importance of a given claim, in what order it should be addressed, what tasks need to be fulfilled to address the claims and what specific parties those tasks should be assigned to. Traditionally, a claims adjuster, who must fulfill each of these steps, handles this process. The process is labor intensive, requires a fair amount of familiarity with the situations similar to the one at hand, and can be subjective, the combination of which results in expense to the insurance company, potential error and inconsistencies.
Loss appraisal involves loss assessment and related activities. In most automobile insurance claims, the damage assessment is developed using computerized damage estimating software. However, conventional computerized estimating platforms utilize incompatible proprietary data and communications formats. Most carriers lack the ability to electronically integrate data from multiple systems, and therefore encourage or require their affiliated repair facilities members to use a specific estimating platform so that the data generated can be analyzed and compared to the results of other estimating resources used by an insurance carrier. In order to communicate with different carriers, repair facilities must often purchase multiple estimating and photo-imaging systems, creating redundant costs and expenses and lost time from having to re-enter data into different proprietary systems.
Claims adjusting involves determining the fair claim settlement amount. Claims adjusting includes investigating the facts related to the claim and negotiating the cost of services to fulfill the claim with other commercial participants and/or settlement negotiations with the client. Traditionally, this process is handled by a claim adjuster, and requires data from a wide and disparate variety of internal and external sources, including computerized and paper-based systems. This problem causes frequent delays as key participants cannot be reached and as required documents are mailed or sent by expensive overnight delivery services.
Satisfying the claim involves completing the services that are required to recompense the loss. The traditional process involves a variety of delays while service providers await approval of adjusters for initial and supplemental costs. During the typical process, the consumer or suppliers to the service provider contacts the carrier or the service provider numerous times by phone. These calls disrupt the normal flow of work for the recipients and add costs and delays to the process. In addition, administrative overhead for repair facilities is high as they must rely on phone and fax to communicate with insurers, suppliers, and consumers.
Settlement and payment involves delivery of the repaired vehicle in the case of repairable damage and payments either directly to the insured or to service providers. In the traditional process, carriers are required to produce multiple checks to a variety of service providers based on manual invoicing methods. Service providers may have to provide their services to the consumer before receiving payment for the work from the carriers and must wait extended periods for final payment. The movement, tracking of numerous payments, often in the form of checks, and the delays commonly involved, are additional problems faced in claims processing.
Management and analysis involves management oversight of the process by commercial participants. Analysis of settlement cycle times, repair costs, revenue, margins, and consumer satisfaction are just a few examples of the business metrics utilized by the Commercial Participants. Gathering and processing of sufficient claim related data such as customer surveys traditionally requires a great amount of resources in the form of time and staff to track down answers, data, and analyze what is gathered. Data gathering traditionally yields a small amount of data making analysis less accurate, and any analysis that is conducted is usually on aging or outdated information.
As each of these processes presents difficulties, complexities to systems and processes which seek to address them, the combination of these processes, each of which needs to be addressed in claims processing, provides even deeper inefficiencies that have yet to be adequately addressed. Traditional claim management systems are each focused on a single or a few of these steps involved in processing claims, and often require the redundant re-collection, re-entry or reformatting of collected information and data to cater to the specific needs of each of the processes involved. For a paper based claim file management system, information is limited to the number of physical copies of the material available, which are static and costly to move and store. In addition, bottlenecks are created when files are kept, for example by a claims adjuster who cannot be reached. For electronic claim management systems, proprietary systems, formats and communication methods similarly require redundant effort in the need to re-enter or reformat data to cater to each system involved in the process. Traditionally, there does not exist a centralized claim processing or storage system. Traditionally, claims processing is people intensive, requiring human involvement for phone calls, data collection and data entry, often requiring several days, and considerable inconvenience to the client while adding significantly to the insurance carrier's costs of adjusting the losses under claims.
Accordingly, there is a need for an automated system for administering, tracking and managing claims processing.